Unveiling New York’s Social Care Networks: A New Era in Community Health

August 13, 2024

Essence Asamoah

The wait is finally over! We are thrilled to announce the new Social Care Networks (SCNs) awarded under New York’s NYHER 1115 Medicaid Waiver. These SCNs are set to transform community health and expand HRSN (Health Related Social Need) services to more New Yorkers in need.

The Newly Awarded SCNs

Congratulations to the 9 newly awarded Social Care Networks across New York. These SCNs will play a pivotal role in providing the community with undeniable improvements in health equity and whole-person care by delivering integrated social and healthcare services. The $500 million program is one component of a $7.5 billion three-year waiver with nearly $6 billion of federal funding. The SCNs will be core to facilitating the delivery of health-related social needs, including nutrition, housing supports, transportation, and case management for eligible Medicaid members, essential to addressing health disparities and improving population health. Here are the awarded SCNs:

Care Compass Collaborative – [Southern Tier]
Finger Lakes IPA Inc. – [Finger Lakes]
Health and Welfare Council of Long Island – [Long Island]
Healthy Alliance Foundation Inc. – [Capital Region, Central NY, North Country]
Hudson Valley Care Coalition, Inc. – [Hudson Valley]
Public Health Solutions – [Manhattan, Queens, Brooklyn]
Staten Island Performing Provider System – [Staten Island]
Somos Healthcare Providers, Inc. – [Bronx]
Western New York Integrated Care Collaborative Inc. – [Western NY]

“The Social Care Networks will help us transform how we support communities with the greatest unmet needs,” Governor Hochul said. “Through the SCN program, we are making a direct investment in the health and wellbeing of our local communities – and New Yorkers will be connected to a more equitable and integrated social and health care system.”

What are Social Care Networks?

Social Care Networks (SCNs) are collaborative networks designed to bridge the gap between healthcare providers, community-based organizations (CBOs), and social service agencies. They function as centralized platforms that facilitate the screening, navigation, and delivery of essential services, particularly those addressing the social determinants of health. By leveraging cutting-edge technology, SCNs adopt a data-driven approach to simplify service coordination and enhance care quality, ensuring comprehensive and integrated support for individuals.

Medicaid members often navigate significant health challenges compounded by socioeconomic factors. SCNs are designed to help these individuals by addressing critical issues like housing instability, food insecurity, and transportation access. By merging primary care with Health-Related Social Needs (HRSN) services, SCNs can enable early intervention and preventive care. This new SCN program reduces reliance on costly emergency room visits and hospitalizations and ensures a more efficient use of Medicaid resources, ultimately enhancing care quality for members.

Following HRSN screening, Medicaid members will be navigated to social care services that most appropriately meet their needs. SCNs will then be accountable for ensuring eligible members are navigated to appropriate social care services delivered by CBOs in their network. Using the SCN’s chosen data and IT platform, they will be expected to “close the loop” on social care services covered by the 1115 waiver. SCNs will be instrumental in ensuring a seamless and efficient member experience from screening to service provision.

All referral data will flow through the SCN’s data and IT platform, supported by the Statewide Health Information Network-New York (SHIN-NY).

Objectives of SCNs:

Improve health outcomes by addressing health-related social needs (HRSNs).
Enhance community support systems through coordinated efforts of CBOs.
Integrate social and healthcare services to provide whole-person care management.

What is Care Management?

Care management is a comprehensive and dynamic process that involves coordinating, supervising, and optimizing all aspects of a member’s care journey. This multifaceted approach includes thorough evaluations to understand the member’s medical, psychological, and social needs, create a personalized care plan, and ensure seamless delivery of healthcare services across various providers. Care managers are critical in facilitating referrals, connecting members with community resources, and providing education and support to members and their families. By adopting a holistic, member-centered approach, care management de-silos the healthcare ecosystem to improve member outcomes, enhance the quality of care, and promote overall health and well-being.

We also predict that the highly anticipated Program Manual will specify care management and care plans will be required within the social care ecosystem to track the long-term outcomes of the SCNs.

Eligibility: SCNs can be led by various non-profit entities, including CBOs, Independent Practice Associations (IPAs), Health Homes, Behavioral Health Care Collaboratives (BHCCs), Federally Qualified Health Centers (FQHCs), or Performing Provider Systems (PPSs) with experience working with CBOs in the region.

Foothold Technology’s Purpose-Built SCN Solutions

At Foothold Technology, we are excited to support these new SCNs, offering care management solutions that ensure program success and make it possible for every person to have a single, comprehensive care plan that informs and is informed by their needs and experiences.

Key Features:

Customizable, Whole-Person Care Plans: Tailor each care plan to meet and adapt to the individual health conditions, life circumstances, and needs of every person served. FCM can organize care plans and ensure that interventions are precisely aligned with clients’ goals and well-being so you can focus on their care.
Comprehensive Outcomes Tracking: Foothold’s DataStudio transcends traditional closed-loop referral metrics to assess health improvements across the community. It provides deep insights into population health trends, enabling SCNs to make informed strategic decisions centered on member health outcomes. This approach tracks and actively improves healthcare delivery, placing member well-being at the forefront of every decision.
Ease of Use for Social Care Navigators: Designed by and for care managers, our FCM platform streamlines member documentation and enhances field efficiency. Care managers can easily document activities, track member progress through intuitive dashboards, and spend less time on administrative tasks.

Foothold also integrates with Unite Us & FindHelp for intuitive workflows, data access, & closed-loop referrals.

The future of healthcare in New York is bright with the award of these new SCNs. And at Foothold Technology, we are prepared to support these networks with our purpose-built solutions, ensuring SCNs can deliver impactful care from day one.

Imagine the impact if a person in need at a food pantry within an SCN ecosystem could be immediately connected to a care manager, revealing and addressing a spectrum of needs. This is the transformative potential of SCNs enabled by Foothold, which is the true ability to drive positive health outcomes in care.

Contact us today for more information on how Foothold Technology can support your SCN.

Social Care Network Resource Library: